I       f^p  .      


HX641 43490 
RC991   Un321916  Instructions  to  exam 

Uj^jl'AllTMENT  OF  THE  INTERIOR. 


RECAP 


BUREAU  OF  PENSIONS 


INSTRUCTIONS 


TO 


EXAMINING  SURGEONS 


APPROVED  JANUARY  3,  1916 


WASHIl,x,TON 

GOVERNMENT  PRINTING  OFFICE 

1915 


V£M 


COLLEGE  OF 

PHYSICIANS  AND  SURGEONS 

LIBRARY 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/instructionstoexOOunit 


3—1573 


DEPARTMENT  OF  THE  INTERIOR 

BUREAU  OF  PENSIONS 


INSTRUCTIONS 


TO 


EXAMINING  SURGEONS 


APPROVED  JANUARY  3,  1916 


WASHIKGTON 

GOVERNMENT  PRINTING  OFFICE 

1915 


IflC 


INSTRUCTIONS  TO  EXAMINING  SURGEONS. 


This  book  is  presented  to  the  examining  surgeons  of  the  Bureau 
of  Pensions  for  their  guidance  in  the  performance  of  their  duties. 

To  insure  completeness .  and  uniformity  in  the  examination  of 
applicants  and  for  purposes  of  record,  it  is  necessary  to  have  a 
definite  and  comprehensive  method  of  procedure. 

This  edition  supersedes  all  others  and  should  be  carefully  read. 

BOARDS  OF  SUSGEONS. 

(1)  Surgeons  are  appointed  by  the  Commissioner  of  Pensions 
under  authority  of  the  law  which  provides: 

That  the  Commissioner  of  Pensions  is  laereby  authorized  to  appoint  surgeons 
wlio,  under  his  control  and  direction,  shall  malve  such  examination  of  pen- 
sioners ar.d  claimants  for  pension  or  increased  pension  as  he  shall  require ; 
and  he  shall  organize  boards  of  surgeons,  to  consist  of  three  members  each,  at 
such  points  in  each  State  as  he  shall  deem  necessary,  and  all  examinations,  so 
far  as  practicable,  shall  be  made  by  the  boards,  and  no  examination  shall  be 
made  by  one  surgeon  excepting  under  such  circumstances  as  make  it  impracti- 
cable for  a  claimant  to  present  himself  before  a  board. 

(2)  After  appointment  the  members  of  the  board  must  organize  by 
selecting  a  president,  secretary,  and  treasurer.  The  place  of  meet- 
ing should  also  be  determined  upon  and  the  bureau  promptly  notified. 
The  member  whose  handwriting  is  most  legible  should  be  selected 
as  secretar3\ 

(3)  The  place  of  meeting  should  not  be  changed  without  permis- 
sion of  the  Commissioner  of  Pensions,  and  such  place  should  be 
centrally  located  and  readily  accessible  to  claimants,  with  comfort- 
able accommodations  for  those  obliged  to  wait. 

(4)  Boards  must  endeavor  to  meet  promptly  at  the  time  agreed 
upon,  which  is  usually  Wednesday  morning  at  10  o'clock.  When  the 
regular  day  of  examination  falls  upon  a  legal  holiday,  the  day  pre- 
ceding it  will  be  considered  the  regular  day. 

(5)  If  it  be  known  prior  to  any  regular  meeting  day  of  a  board  that 
no  meeting  can  be  held,  all  claimants  for  whose  examination  the 
board  holds  orders  should  be  notified  that  no  session  will  be  held  on 
that  day.  If  on  a  regular  examination  day  a  board  holds  no  valid 
order  for  examination,  the  meeting  for  that  day  may  be  omitted. 

(6)  Under  no  circumstances  can  a  surgeon  delegate  to  another  the 
work  imposed  upon  himself.  If  a  surgeon  is  compelled  to  be  absent 
from  the  sessions  of  the  board  for  any  extended  time,  by  reason  of 
sickness  or  other  cause,  the  bureau  should  be  notified.  The  death  of 
any  member  should  be  promptly  reported. 

(7)  A  surgeon  who  desires  a  leave  of  absence  should,  if  possible, 
make  application  therefor  at  least  30  days  in  advance  of  the  date 
he  desires  it  to  commence,  giving  the  dates  when  he  wishes  such  leave 
to  begin  and  end. 

3 


4  IIsrSTRUCTIONS   TO   EXAMINING  SUKGEONS. 

(8)  Leave  of  absence  can  not  be  given  to  two  members  of  a  board 
to  cover  the  same  period  of  time.  A  leave  for  a  greater  time  than 
60  days  will  not  generally  be  granted.  If  the  surgeon  is  compelled 
to  be  away  for  a  longer  period  than  60  days,  he  should  tender  his 
resignation. 

(9)  Change  of  residence  of  a  member  of  a  board  to  such  distance 
as  will  prevent  his  regular  attendance  upon  the  sessions  of  the  board 
will  nullify  his  appointment. 

(10)  No  examining  surgeon  may  act  as  the  attorney  or  representa- 
tive of  any  person  in  the  matter  of  a  pension  claim. 

(11)  When  no  board  or  single  surgeon  is  accessible,  the  commis- 
sioner may  authorize  the  postmaster  at  the  claimant's  home  to  select 
a  civil  surgeon  to  make  the  examination. 

(12)  Two  orders  are  issued  for  every  examination,  one  to  the 
board  and  the  other  to  the  claimant.  AVhen  the  claimant  presents 
his  order  it  should  be  found  to  agree  in  name,  number,  etc.,  with  that 
in  possession  of  the  board.  If  the  board  holds  no  corresponding 
order,  it  will  generally  be  found  that  the  claimant's  order  is  directed 
to  some  other  board,  and  in  such  case  no  examination  will  be  made, 
and  the  claimant  will  be  properly  advised.  If,  however,  claimant 
presents  himself  with  a  current  order  properly  directed  to  the  board, 
and  no  corresponding  order  is  on  file,  an  examination  should  be 
made,  and  in  such  case  the  claimant  must  be  questioned  as  to  all  of 
his  alleged  disabilities  in  order  that  none  may  be  omitted  in  the 
certificate. 

(13)  If,  on  the  other  hand,  the  board  has  an  order  and  the  claim- 
ant presents  himself  without  one,  the  board,  after  satisfying  itself 
of  the  identity  of  the  claimant,  should  proceed  with  the  examination. 

(14)  If  a  surgeon  receives  an  order  for  examination  which  was 
improperly  mailed  and  was  intended  for  another,  he  should  promptly 
return  the  same  to  the  bureau  with  an  explanation. 

(15)  Orders  for  examination  are  generally  valid  for  three  months 
from  the  date  of  same.  They  should,  however,  be  kept  until  the  first 
meeting  of  the  board,  following  the  expiration  of  the  three  months 
limit,  when,  if  the  claimant  appears,  he  should  be  examined.  Should 
he  not  appear  at  this  session,  the  order  should  be  indorsed,  "  Claim- 
ant failed  to  appear  toithin  speci^ed  time^''  dated,  and  returned  to 
the  bureau. 

(16)  If  an  examination  is  made,  the  order  should  be  inclosed  with 
the  certificate  and  the  voucher. 

(17)  The  claimant's  order  should  be  dated,  signed,  and  handed  to 
him  before  he  leaves  the  examining  room. 

(18)  No  examination  made  by  a  single  member  of  a  board  will  be 
accepted  unless  such  examination  is  made  upon  a  special  order  from 
the  bureau.  It  is  desired  that  all  examinations  be  made  by  a  full 
board ;  but  if  one  member  is  absent,  the  examination  may  proceed  if 
the  claimant  signs  the  waiver  upon  the  back  of  the  certificate,  con- 
senting to  an  examination  by  two  members. 

(19)  If  the  claimant  is  unable  to  sign  his  name,  his  mark  to  the 
waiver  must  be  witnessed  by  two  persons  who  can  write,  one  of 
whom,  at  least,  must  not  be  a  member  of  the  board. 

Under  no  circumstances  must  the  secretary  sign  the  waiver  for 
the  claimant. 


INSTEUCTIOXS    TO    EXAMINING   SURGEONS.  5 

(20)  If  ii  full  board  is  present,  the  secretary  will  certify,  in  the 
proper  form  on  the  back  of  the  certificate,  to  the  presence  of  the 
full  board  and  their  participation  in  the  examination. 

(21)  "When  an  examination  is  made  by  one  member  of  a  board  on  a 
special  order,  or  by  a  single  surgeon  or  expert,  it  will  not  be  necessary 
for  the  claimant  to  sign  a  waiver. 

(22)  When  an  orcTer  for  examination  is  marked  "Test,"  it  is 
because  there  have  been  differences  of  opinion  as  to  some  pathological 
sequence,  or  even  as  to  the  existence  of  the  alleged  disability.  Such 
examinations  should  be  made  with  unusual  care. 

(23)  If  a  member  of  a  board  can  not  agree  with  his  colleagues  as 
to  their  findings  in  a  given  case,  he  may  prepare  a  minority  certificate 
on  an  entirely  separate  blank  and  forward  the  same.  Every  effort 
should,  however,  be  made  to  reconcile  conflicting  opinions  and  avoid 
the  annoyance  of  a  minority  report. 

(24:)  Boards  may  employ  a  stenographer  or  clerk,  but  at  their  own 
expense  and  on  their  own  responsibility.  At  an  examination,  mem- 
bers of  the  board,  one  claimant  and  such  clerk  may,  and  no  other  per- 
son shall  be  present,  except  that  a  properly  accredited  special  exam- 
iner as  a  representative  of  the  bureau,  may  be  permitted  to  be  present. 

(25)  "When  the  board  is  in  session,  all  communications  relating  to 
the  business  of  the  bureau  received  since  the  last  meeting  should  be 
read  by  the  secretary,  and  the  work  of  the  examination  should  begin 
promptly. 

(26)  i?he  claimants  should  be  taken  in  the  order  of  their  arrival, 
though  if  a  certain  one  is  very  feeble  or  is  obliged  to  take  an  early 
train  to  get  home,  those  waiting  may  be  asked  to  waive  their  turn. 

(27)  Each  claimant  should  be  given  an  opportunity  to  make  a 
brief  statement  as  to  his  disabilities  and  must  declare  that  the  dis- 
abilities named  are  the  only  ones  contracted  in  the  service  that  now 
affect  him. 

(28)  All  claimants  who  present  themselves  on  a  given  day  should 
be  examined,  nnless  the  number  exceeds  twenty,  in  which  case  the  law 
provides  as  follows: 

And  hereafter  each  member  of  each  examining  board  shall  receive  the  sum  of 
three  dollars  for  the  examination  of  each  applicant  whenever  five  or  a  less  num- 
ber shall  be  examined  on  any  one  day :  Provided,  That  if  twenty  or  more  appli- 
cants appear  on  one  day,  no  fewer  than  twenty  shall,  if  practicable,  be  examined 
on  said  day,  and  that  if  fewer  examinations  be  then  made,  twenty  or  more  having 
appeared,  then  there  shall  be  paid  for  the  first  examinations  made  on  the  next 
examination  day  the  fee  of  one  dollar  only  until  twenty  examinations  shall  have 
been  made.     (Act  approved  May  28,  1908.) 

(29)  If,  therefore,  a  greater  number  of  claimants  appears  on  a 
given  day  than  can  properly  be  examined,  an  adjourned  meeting  Avill 
be  held  on  the  succeeding  day,  and  the  examination  will  be  continued ; 
and  the  certificates  made  under  such  circumstances  must  bear  the 
actual  date  of  examination  and  be  indorsed  "Adjourned  meeting." 

(30)  A  board  may  notify  a  claimant  of  the  receipt  of  an  order  for 
his  examination,  but  not  after  the  validity  of  the  same  has  ceased, 
and  may  also  ask  the  claimant  to  return  for  a  reexamination  if 
necessary. 

(31)  \Yhen  a  claimant  furnishes  good  evidence  that  he  is  so  dis- 
abled that  he  can  not  present  himself  before  a  board,  a  so-called  home 
examination  is  ordered,  in  which  case  any  member  of  the  board,  unless 
some  special  one  is  designated,  will  proceed  to  the  claimant's  residence 


6  INSTRUCTIONS   TO   EXAMINING  SUEGEONS. 

at  the  earliest  possible  moment  and  make  the  examination;  but  the 
member  who  lives  nearest  to  the  home  of  the  applicant  should  gener- 
ally make  the  examination. 

If,  however,  after  such  an  order  is  issued,  the  claimant  should  pre- 
sent himself  for  examination,  or  it  should  come  to  the  knowledge  of 
the  surgeon  that  he  is  able  to  do  so,  the  home  examination  should  not 
be  made,  but  he  should  be  examined  by  two  or  more  members  of  the 
board  in  the  one  contingency,  or  notified  to  appear  for  examination  in 
the  other. 

(32)  "The  fee  for  each  examination  at  the  claimant's  residence, 
provided  his  residence  is  outside  of  the  corporate  limits  of  the  place 
of  the  regular  meeting  of  the  examining  board  and  of  the  place  of  resi- 
dence of  the  surgeon  making  the  examination,  shall  be  $5  in  addition 
to  the  payment  of  the  actual  traveling  expenses  of  the  surgeon."  The 
fee,  however,  for  a  home  examination,  when  the  conditions  are  other 
than  those  provided  for  above,  will  be  $3. 

(33)  If,  for  any  satisfactory  reason,  no  member  of  a  board  can 
make  a  given  home  examination,  the  papers  should  be  returned  to  the 
bureau  at  once  with  an  explanation. 

(34)  No  discussion  or  correspondence  should  be  held  with  claim- 
ants who  find  fault  with  the  rate  allowed  by  the  bureau,  and  under  no 
circumstances  should  the  certificate  of  examination  or  any  part 
thereof  be  shown  to  a  claimant  or  other  person  or  read  in  his  i^res- 
ence;  nor  should  the  claimant  or  any  other  person  be  told  by  the 
examiners  or  either  of  them  how  the  claimant  has  been  rated  by  the 
board. 

Dissatisfied  claimants  may  be  told  that  the  bureau  in  all  cases 
reserves  the  right  to  fix  the  ultimate  rate. 

(35)  AVhen  a  claimant  for  pension  requests  an  examining  surgeon 
to  make  a  private  examination  and  affidavit  in  support  of  his  claim, 
he  shall  refuse  to  do  so;  but  if  the  examining  surgeon  is  at  the  same 
time  the  family  physician  of  the  claimant,  or  has  attended  him  pro- 
fessionally in  the  past,  he  may  testify,  and  he  should  incorporate  in 
his  affidavit  a  statement  that  he  is  the  family  physician. 

•  (36)  No  examining  surgeon  shall  demand  or  accept  a  fee  from  any 
claimant  for  services  rendered  in  connection  with  his  official  exami- 
nation. 

(37)  An  examining  surgeon  who  is  also  a  pension  claimant  should 
not  be  examined  by  a  board  of  which  he  is  a  member.  If  such  an 
order  is  received,  it  has  been  sent  out  erroneously,  and  shoiild  be 
returned  to  the  bureau  with  an  explanation. 

(38)  If  a  claimant  has  made  a  long  trip  to  obtain  his  examination, 
and  through  misunderstanding  arrives  upon  the  wrong  day,  if  at  least 
two  members  of  the  board  can  be  convened,  the  examination  should 
be  made  and  an  explanation  forwarded  with  the  certificate. 

(39)  The  requisition  for  blanks  (Form  3-116)  indicates  all  the 
issues  for  official  use,  and  it  will  be  useless  to  make  request  for  other 
blanks.  This  form  should  be  used  only  for  the  purpose  intended  and 
should  be  mailed  to  the  bureau  in  a  separate  envelope. 

EXAMINATIONS. 

The  act  of  Congress  approved  May  28,  1908,  provides  as  follows: 
"  That  no  fee  shall  be  paid  to  any  member  of  an  examining  board 


INSTRUCTIONS   TO   EXAMINING  SUEGEONS.  7 

unless  personally  present  and  assisting  in  the  examination  of  appli- 
cant, and  the  report  of  such  examining  surgeons  shall  specifically  and 
accurately  set  forth  the  physical  condition  of  the  applicant,  each  and 
every  existing  disability  being  fully  and  carefully  described." 

(40)  The  necessity  of  removing  all  the  claimant's  clothing  before 
examination  must  be  decided  by  the  board,  and  will  depend,  of  course, 
upon  the  nature  of  the  disability.  It  is,  however,  proper  for  the  board 
to  insist  upon  the  removal  of  the  clothing  if  deemed  necessary. 

(41)  The  bureau  desires  in  these  examinations  a  concise  but  clear 
description  of  all  the  disabilities  from  which  the  claimant  is  suffering, 
whether  included  in  the  order  or  not.  Claimants  often  make  obscure 
allegations,  and  these  are  copied,  as  required  by  regulations  of  the 
bureau,  upon  the  order  of  examination  in  the  routine  of  office  work. 
The  board  can,  by  judicious  questioning,  often  arrive  at  the  real  dis- 
ability which  the  claimant  means  to  allege,  but  does  not,  and  can  thus 
give  a  clear  idea  of  the  actual  disabling  cause.  The  certificate  must 
cover  all  alleged  causes  of  disability,  for  the  claim  can  not  be  adjudi- 
cated in  the  bureau  unless  every  one  is  disposed  of  by  the  surgeons. 

(42)  Disabilities  that  are  pathologically  connected  may  be  grouped 
together  under  a  single  head,  but  it  will  assist  the  bureau  if  in  general 
the  disabilities  are  taken  up  in  the  succession  in  which  they  occur  in 
the  order  and  if  a  separate  paragraph  is  made  for  every  one. 

(43)  It  often  happens  that  some  member  of  a  board  has  knowledge 
of  the  disability  for  which  the  claimant  is  pensioned  or  is  seeking  pen- 
sion, and  it  is  proper  for  this  member  to  incorporate  in  the  certificate 
as  a  separate  paragraph  what  he  may  personally  know  as  to  the  cause 
and  extent  of  claimant's  disability. 

(44)  If  such  member  of  a  board  personally  knows  that  the  disabil- 
ity for  which  the  claimant  is  pensioned  or  seeking  pension  under  the 
general  law  has  been  caused  or  aggravated  by  some  injury  or  accident 
occurring  outside  of  the  service,  or  is  caused  by  the  claimant's  own 
vicious  habits,  it  will  be  his  duty  to  state  such  knowledge. 

(45)  The  results  of  advancing  age  should  be  observed,  and  its 
effects  upon  the  disabilities  should  be  excluded  by  the  board.  Every 
disability  the  result  of  age  alone  should  be  described. 

(46 )  Every  certificate  should  contain  a  brief  report  of  the  condition 
of  the  lungs  and  heart  and  the  results  of  urinalysis,  even  though  dis- 
ease of  these  organs  and  kidneys  is  not  alleged. 

(47)  Gunshot  wounds  and  injuries. — The  site  of  all  wounds  and 
injuries  must  be  indicated  on  the  diagrams  on  the  back  of  the  cer- 
tificate. 

{a)  The  points  of  entrance  and  exit  of  a  missile  and  the  point  of 
section  of  all  amputations  should  also  be  carefully  marked.  This  is 
important  and  should  not  be  neglected. 

(&)  Scars  should  be  fully  described  and  a  statement  made  as  to 
whether  they  are  tender,  adherent,  or  dragging.  If  there  is  loss  of 
tissue  or  atrophy,  give  comparative  measurements. 

(c)  Is  there  deformity,  limitation  of  motion,  lameness,  or  necessity 
for  artificial  aid,  such  as  crutches  or  canes? 

{d)  If,  in  the  opinion  of  the  board,  there  are  sequelae  of  either 
injuries  or  gunshot  wounds,  whether  alleged  or  not  by  the  claimant, 
they  should  be  fully  described,  and  the  reasons  for  considering  them 
sequelae  should  be  stated. 


8  HSrSTBUCTIONS   TO   EXAMINING  SURGEONS. 

(48)  Amputations. — In  amputations  of  the  leg  above  the  knee 
cr  arm  above  the  elbow  it  will  be  necessary  to  state  the  length  of  the 
remaining  portion  of  bone  by  measurement  from  the  great  trochanter 
or  acromion  process  to  the  point  of  section  of  the  bone. 

If  the  claimant  states  that  he  is  unable  to  wear  an  artificial  lunb, 
the  stump  should  be  carefully  examined  to  determine  whether  there 
is  any  permanent  condition  that  would  prevent  the  use  of  a  properly 
fitted  artificial  limb. 

(49)  If  an  amputation  is  near  but  below  the  knee,  it  should  be 
stated  whether  the  point  of  section  is  above,  through,  or  below  the 
tubercle  of  the  tibia. 

(50)  Where  an  amputation  is  near  but  below  the  elbow,  state 
whether  the  point  of  section  is  above,  through,  or  below  the  base  of 
the  head  of  the  radius. 

(51)  In  amjDutation  of  the  fingers  or  toes,  use  the  word  proximal  or 
distal  joint  instead  of  the  word  first  or  last  joint  to  indicate  the  point 
of  section. 

(52)  In  every  amputation  the  condition  of  the  stump  as  to  suffi- 
ciency of  covering,  sensitiveness,  and  painfulness  should  be  given, 
and  the  point  of  section  should  be  indicated  on  the  diagram. 

(53)  In  case  of  injury  to  an  arm  or  leg,  if  total  disability  of  the 
member  is  alleged  or  found,  great  care  should  be  taken  in  the  descrip- 
tion of  the  bones,  joints,  tendons,  ligaments,  and  muscles;  and  the 
uses  to  which  the  arm,  leg,  hand,  or  foot  can  and  can  not  be  put 
should  be  clearly  stated. 

(54)  Hernia. — Impulse  alone  can  not  be  accepted  as  evidence  of  a 
hernia.  A  definite  statement  should  be  made  as  to  whether  a  hernial 
tumor  is  or  is  not  present.  If  there  is  a  tumor,  its  size  and  situation 
with  reference  to  the  abdominal  rings  and  Poupart's  ligament  should 
be  clearly  described.  If  the  hernia  is  inguinal,  is  it  oblique  or  direct  ? 
In  the  case  of  an  oblique  hernia  a  statement  should  always  be  made 
to  the  effect  that  the  mass  does  or  does  not  pass  through  the  external 
ring.  In  other  words,  state  as  positively  as  possible  whether  the 
hernia  is  complete  or  incomplete. 

Note  all  complications,  and  state  whether  the  tumor  can  be  readily 
reduced  and  retained  by  a  truss.  Does  the  applicant  habitually  wear 
a  truss? 

The  condition  of  the  abdominal  rings  should  be  investigated  and 
noted.    Has  the  hernia  ever  become  strangulated? 

(55)  If  double  inguinal  hernia  is  found,  each  should  be  separately 
and  distinctly  described. 

(56)  An  abdominal,  umbilical,  or  femoral  hernia  should  also 
receive  careful  attention  and  thorough  description. 

Note. — The  Bureau  of  Pensions  has  nothing  to  do  with  furnishing 
trusses,  and  all  correspondence  relating  thereto  should  be  addressed  to 
the  Surgeon  General  United  States  Army,  War  Department,  Wash- 
ington, D.  C. 

(57)  Varicose  veins. — Wlien  varicose  veins  of  one  leg  only  are 
alleged,  the  examination  must  always  include  both  extremities.  Indi- 
cate on  the  diagram  the  extent  of  surface  involved.  The  names  of 
the  affected  veins  and  their  size  in  fractions  of  an  inch,  should  be 
given.    If  there  are  ulcers,  give  position,  size,  and  condition. 

(58)  Rheumatism. — When  this  disability  is  alleged,  the  certificate 
should  show  the  condition  of  the  joints,  tendons,  and  muscles  in 


iisrsTTiucTioisrs  to  examining  suegeons.  9 

general,  but  more  especially  of  those  involved  in  rheumatism.  If 
there  is  limitation  of  motion  in  joints,  give  degree  of  same.  Show 
atrophy  of  muscles  by  comparative  measurements.  Crepitation  of 
joints  can  not  be  accepted  alone  as  showing  rheumatism,  but  will  be 
estimated  by  the  board,  in  connection  with  objective  and  subjective 
symptoms,  in  affixing  the  rate. 

When  rheumatism  is  alleged  the  heart  should  always  be  examined. 

(59)  Malarial  poisoning ;  ehills  and  fever. — Is  the  claimant  suffer- 
ing from  active  malarial  disease  or  its  sequelae  at  the  present  time? 
Does  he  now  reside  in  a  locality  where  malarial  diseases  are  prevalent  ? 
He  should  be  questioned  as  to  the  date  of  his  last  chill  and  the  fre- 
quency of  such  attacks,  and  should  also  have  full  opportunity  to 
explain  his  subjective  symptoms. 

(60)  The  general  appearance  of  the  claimant,  including  the  color 
of  the  skin  and  conjunctiva,  should  be  described.  The  areas  of 
hepatic  and  splenic  dullness  should  be  given,  and,  if  abnormality  is 
shown,  the  areas  should  be  marked  on  the  diagram.  To  which  ribs 
do  the  upper  and  lower  borders  of  the  liver  correspond?  Does  the 
lower  border  extend  below  the  ribs  in  the  nipple  and  axillary  lines 
and,  if  so,  how  far?     Is  the  spleen  palpable? 

(61)  Diseases  of  the  'brain  and  spinal  cord. — Describe  all  objective 
evidence  of  injury  to  the  cranium  and  contents  and  to  the  spinal  col- 
umn. Describe  all  motor  or  sensory  disturbances  and  outline  areas  of 
anaesthesia  or  hyperaesthesia.  Is  there  hemiplegia?  If  so,  describe 
the  same  and  report  the  presence  or  absence  of  arteriosclerosis.  Is 
there  paraplegia  or  paresis?  Are  there  attacks  of  vertigo,  spasms,  or 
convulsions?  If  epilepsy  exists,  secure  a  statement  as  to  the  fre- 
quency, duration,  and  violence  of  the  seizures. 

(62)  If  insanity  is  found,  describe  the  mental  conditions  and  state 
whether  there  is  disorientation  in  any  field.  Is  the  claimant  kept 
under  restraint  or  is  restraint  necessary?  Does  he  perform  any 
labor  ? 

(63)  Are  the  pupillary  and  other  reflexes  normal  ?  Is  there  a  sense 
of  constriction  about  the  thorax  or  abdomen  or  of  cushion  beneath 
the  feet,  numbness  of  limbs,  or  incoordination  of  movements?  Is  the 
claimant  able  to  approximate  the  tips  of  his  fingers  and  to  button 
his  clothes?  Can  he  stand  and  walk  with  his  eyes  closed?  Is  there 
muscular  tremor  ?    Is  it  intentional  ? 

(64)  In  all  cases  of  disease  of  brain  or  spinal  cord  its  possible 
syphilitic  origin  must  be  remembered  and  investigated. 

(65)  Sunstroke. — ^A  detailed  statement  as  to  all  alleged  results  of 
sunstroke  should  be  obtained  from  the  claimant,  and  all  objective 
symptoms  of  disease  of  brain  noted.  Are  there  evidences  of  chronic 
meningitis,  impairment  of  memory  or  mental  faculties?  Is  there 
complaint  of  habitual  headache,  vertigo,  or  intolerance  of  heat? 

(66)  Diseases  of  lungs. — Measure  the  chest  at  rest,  on  full  inspira- 
tion and  expiration.  In  cases  of  asymmetry  give  bilateral  measure- 
ments. Note  all  deformities,  pleuritic  effusions,  and  adhesions.  In 
tuberculosis  determine  areas  of  dullness  and  whether  cavities  exist. 
Has  there  been  haemoptysis  ?    If  so,  when  and  how  frequently  ? 

When  the  board  is  possessed  of  the  necessary  appliances,  a  micro- 
scopical examination  of  the  sputum  in  appropriate  cases  of  disease 
of  lungs  will  be  appreciated. 
15614°— 15 2 


10  IlSrSTKUCTIOXS   TO   EXAMIK"IiSrG  SUEGEOI^J'S. 

In  all  examinations  of  the  lungs  the  heart  must  be  included. 

(67)  Diseases  of  heart. — The  heart  should  be  examined  when  the 
claimant  is  at  rest.  The  point  of  apex  impulse  should  be  located  and 
a  statement  made  whether  it  is  evident  to  inspection  and  palpation. 
The  area  and  position  of  cardiac  dullness  and  departures  from  normal 
rhythm  should  be  given. 

If  there  are  murmurs,  state  with  which  sound  they  are  heard,  where 
they  are  most  distinct  and  at  which  orifice  the}^  arise.  Is  there  hyper- 
trophy or  dilatation  ?  Are  there  indications  of  failing  compensation  ? 
Is  there  dyspnoea  before  or  after  exercise?  Is  there  cyanosis  or 
oedema  %  If  cyanosis  and  oedema  afe  present,  state  their  location  and 
extent.  If  tachj^cardia  without  organic  lesion  is  found,  determine,  if 
possible,  the  cause  of  same. 

(68)  If  there  is  cardiac  dyspnoea,  do  not  confound  the  same  with 
asthma  due  to  other  causes. 

(69)  Diseases  of  the  hidneys. — The  color,  specific  gravity,  and 
reaction  of  the  urine  should  be  given,  and  tests  for  albumin  and  sugar 
made.  The  tests  employed  should  be  named,  and  any  abnormal  de- 
posits should  be  fully  described. 

Has  the  skin  a  normal  color  and  appearance  ?  Are  there  local  oede- 
mas  ?    Are  there  any  uraemic  symptoms  ? 

(TO)  Diseases  of  the  hlaclder. — Is  there  incontinence  or  retention 
of  urine?  Is  there  irritability  of  the  bladder  or  cystitis?  Is  there 
hypertrophy  of  the  prostate  gland;  if  so,  is  it  due  to  senile  causes, 
and  at  what  age  did  it  develop  ? 

(71)  Diseases  of  genital  organs. — Examine  the  penis  for  scars, 
strictures,  or  discharge.  Interrogate  claimant  for  history  of  gonor- 
rhea.   Are  the  testicles  of  normal  size  and  sensitiveness  ? 

(72)  If  there  is  hj^drocele,  give  careful  differential  diagnosis  from 
varicocele  and  hernia,  state  size  of  sac,  frequency  of  tapping,  and  com- 
plications that  may  be  found. 

(73)  In  varicocele  give  size  of  mass,  differentiate  from  hydrocele 
and  hernia,  and  state  condition  of  scrotal  contents. 

(74)  Syphilis. — If  suspicion  arises  that  syphilis  has  existed,  an 
effort  should  be  made  to  obtain  a  history  of  this  disease.  Scars  of 
chancres  should  be  sought  for,  and  the  lymphatic  glands  usually  in- 
volved should  be  examined. 

The  condition  of  the  palate,  throat,  nasal  passages,  skin,  hair,  tibia, 
and  other  bones  should  be  stated. 

Evidences  of  tertiary  lesions  in  brain,  spinal  cord,  or  elsewhere 
should  be  sought. 

(75)  Chronic  diarrhea. — When  this  disability  is  alleged,  the 
claimant  should  be  measured  and  weighed  with  unusual  care,  and 
his  general  appearance  noted.  The  condition  of  the  stomach,  liver, 
spleen,  rectum,  and  lungs  should  be  fully  described.  Examinations 
for  chronic  diarrhea  should  always  include  a  description  of  the 
rectum. 

(76)  Diseases  of  the  rectum. — The  rectum  should  be  examined 
either  digitally  or  by  the  speculum  and  all  abnormalities  noted. 

If  there  are  piles,  give  their  number,  size,  and  condition,  and  state 
whether  they  are  internal  or  external.  If  there  is  a  fissure,  fistula  or 
stricture,  a  full  description  is  necessary.  Is  there  prolapse  of  the 
rectum?  If  so,  is  it  constant  or  does  it  appear  only  upon  straining? 
Measure  its  extent  and  report  in  inches  and  fractions  thereof  the  size 


INSTEUCTIONS   TO   EXAMINING  SUEGEOXS.  11 

of  the  mass.     Can  it  be  readil}^  reduced?     Is  there  incontinence  of 
feces?     Is  a  rectal  pad  or  bandage  worn  or  needed ? 

(77)  Diseases  of  the  eyes. — These  affections  demand  extreme  care 
on  the  part  of  the  surgeons,  and  the  examination  should  ]Droceed 
methodically,  as  follows: 

{a)  The  lids  should  be  everted  and  the  conjunctiva  carefully  in- 
spected. Is  there  trachoma,  blepharitis,  or  pterygium?  Is  there 
trichiasis,  ectropion,  or  entropion? 

(6)  Is  the  cornea  transparent,  or  are  there  opacities  or  pannus ;  and 
if  so,  how  much  of  the  cornea  do  they  cover  ? 

(c)  Are  the  pupils  of  the  average  normal  size,  and  do  they  respond 
readily  to  light  ?     Are  there  synechias  ? 

{d)  In  affections  of  the  deeper  structures  of  the  eye,  including  the 
crystalline  lens,  the  ophthalmoscope  and  oblique  illumination  must  be 
used,  and  any  variation  from  the  normal  condition  of  the  parts  must 
be  described. 

(78)  In  any  affection  of  the  eyes,  such  as  cataract,  which  the  sur- 
geons believe  to  be  a  result  of  senility,  it  will  be  their  duty  to  state 
this  opinion. 

(79)  Each  board  must  supply  itself  with  a  card  of  Snellen's  test 
types.  This  card  should  be  hung  in  a  good  light,  at  a  distance  of  20 
feet  from  the  claimant.  Each  eye  must  be  covered  in  turn  while  the 
vision  of  its  fellow  is  tested. 

The  largest  type  on  the  card  is  numbered  200,  while  the  smallest  is 
generally  20  or  15.  Eecord  the  smallest  type  that  can  be  read  at  20 
feet  with  each  eye,  and  make  the  number  of  this  type  the  denominator 
of  a  fraction  in  your  record,  while  the  distance  at  which  it  is  read,  or 
20  feet,  will  be  made  the  numerator.  Thus :  If  the  claimant  at  20  feet 
from  the  card  can  read  with  the  right  eye  the  type  numbered  50,  and 
can  read  no  farther,  record  the  vision  of  the  right  eye  as  f^.  If  the 
left  eye  under  similar  circumstances  can  read  only  the  largest  letter, 
or  No.  200,  record  the  vision  of  the  left  eye  as  -^^. 

If  the  vision  is  so  poor  that  none  of  the  letters  can  be  read  at  20 
feet,  bring  the  card  slowly  toward  the  claimant  until  some  of  the 
letters  can  be  seen.  The  numerator  of  the  recording  fraction  will  then 
be  the  new  distance  of  the  card  from  the  claimant,  while  the  denomi- 
nator will  be  the  number  of  the  type,  as  before. 

For  the  sake  of  uniformity,  use  only  the  foot  as  the  unit  of  measure- 
ment for  recording  vision. 

(80)  The  test  of  vision  frequently  employed  by  examining  sur- 
geons, viz,  reading  from  a  book  or  newspaper,  is,  by  itself,  of  no  value 
to  this  bureau. 

(81)  Each  board  should  provide  itself  with  the  means  of  determin- 
ing refractive  defects,  and  state  what  kind  of  anomaly  exists,  and 
the  record  of  visual  power  should  be  made  after  such  error  is  cor- 
rected by 'the  proper  glasses. 

If  the  claimant  wears  glasses  for  distant  use,  as  in  walking  about, 
the  tests  of  vision  should  be  made  while  these  glasses  are  over  the 
eyes;  but,  of  course,  reading  glasses  should  not  be  before  the  ej^es 
while  testing  distant  vision. 

(82)  The  surgeons  should  differentiate  between  the  loss  of  sight  of 
an  eye  and  the  actual  loss  of  an  eyeball.  If  an  eyeball  is  shrunken  or 
collapsed,  the  surgeon  must  state  the  extent  to  which  it  is  atrophied, 


12  liSrSTKUCTIONS   TO    EXAMINHSTG   SURGEONS. 

giving  exact  size  of  stump.     If  the  eye  has  been  enucleated,  it  will  be 
necessary  to  so  state. 

(83)  Nasojyharyngeal  catcnTh. — Describe  condition  of  anterior 
and  posterior  nares  and  tonsils.  Are  the  Eustachian  tubes  pervious  ? 
In  every  case  of  catarrh  an  examination  should  be  made  for  impaired 
hearing.     (See  paragraph  as  to  deafness.) 

(84)  Diseases  of  the  ear — Deafness. — In  all  cases  the  ear  should  be 
thoroughl}^  examined  by  the  speculum  after  removing  any  collection 
of  cerumen.  The  external  auditory  apparatus,  membrana  tympani, 
and  nasopharynx  should  be  described,  and  if  deafness  exists,  the  de- 
gree in  each  ear  must  be  expressed  in  terms  suggested  in  the  following 
j)aragraph : 

(85)  Degrees  of  deafness  are  to  be  rated  as  "slight,"  "severe," 
"nearly  total,"  and  "total,"  and  will  hereafter  be  described  as 
follows : 

Slight  deafness  of  one  ear. — ^Inability  to  hear  ordinary  conversa- 
tion at  6  feet. 

Severe  deafness  of  one  ear. — Inabilitj^  to  hear  loud  conversation 
at  3  feet. 

Nearly  total  deafness  of  one  ear. — Inability  to  hear  the  loudest  dis- 
tinct conversation  at  1  foot. 

Total  deafness  of  one  ear. — Inability  to  hear  the  loudest  conversa- 
tion. 

4^86)  In  every  case  it  will  be  necessary  for  the  board  to  state  the 
distance  at  which  the  claimant  can  hear  the  standard  tones  indicated 
above.,  as  well  as  the  distance  at  u-hich  he  can  not  hear  thenfi.  Thus, 
in  a  case  of  slight  deafness  it  should  be  certified  that  claimant  can 
not  hear  ordinary  conversation  at  6  feet,  but  can  hear  same  at  1  or  2 
feet,  as  the  facts  may  warrant,  etc. 

(87)  Let  each  ear  be  tested  alone  by  occluding  the  opposite  ear  as 
thoroughly  as  possible,  and  by  directing  the  conversation  from  various . 
points  "and  from  such  positions  that  the  claimant  ma}^  not  see  the 
movements  of  the  lips.    Make  a  separate  and  distinct  report  for  each 
ear  in  conformity  with  the  above  definitions. 

(88)  If  artificial  means,  such  as  trumpets,  conversation  tubes,  etc., 
are  necessary  to  assist  the  sense  of  hearing,  the  board  will  state  this 
fact. 

(89)  In  cases  of  alleged  total  deafness  the  surgeon  should  state 
the  method  of  communicating  with  the  claimant. 

(90)  It  is  expected  that  your  examination  will  be  conducted  with 
such  tact  that  you  will  not 'be  deceived  by  the  claimant's  statements, 
and  so  that  you  may  state  positively  that  such  degrees  of  deafness  as 
you  describe  actually  exist.  Let  all  your  conversation  with  a  claimant 
for  deafness  be  conducted  while  he  is  off  his  guard,  with  a  view  to  test 
the  correctness  of  your  report. 

CERTIFICATES  OE  MEDICAL  EXAMINATION. 

(91)  The  preparation  of  the  certificates  is  an  important  part  of 
your  duty  and  should  not  be  slighted.  These  certificates  remain  per- 
manently attached  to  the  cases  and  are  a  sort  of  record  of  vour  pro- 
fessional work.  They  should  be  written  in  a  legible  hand,  with  undi- 
luted black  ink,  though  typewritten  work  is  much  preferred.    Crowd- 


INSTEUCTIONS    TO    EXAMINING   SURGEONS.  13 

ing  of  words,  interlineations,  abbreviations,  and  use  of  the  margins 
for  writing  upon  should  be  avoided. 

(92)  A  continuation  blank  is  provided  m  case  a  single  sheet  is  not 
sufficient  for  the  certificate ;  and  if  used,  it  should  be  attached  to  the 
certificate  blank,  properly  briefed,  dated,  and  signed. 

(93)  These  blanks  must  never  be  used  for  any  purpose  other  than 
•official  certificates. 

(94)  The  blank  spaces  at  the  top  of  each  certificate  must  be  filled, 
taking  care  that  the  date  is  that  of  the  examination  and  not  that  of 
the  construction  of  the  certificate.  The  date  upon  the  back  of  the 
certificate  and  that  upon  the  face  should  be  the  same. 

(95)  The  certificate  should  close  with  a  statement  to  the  effect  that 
except  as  described  no  other  disability  is  found  and  that  the  disabili- 
ties are  not  due  to  vicious  habits,  where  such  a  statement  is  applicable. 

(96)  When  a  certificate  of  medical  examination  does  not  cover  all  of 
the  disabilities  or  is  otherwise  defective  a  call  will  be  made  for  amend- 
ment. The  amendment  blank  should  receive  the  date  of  the  original 
certificate,  the  amendment  bearing  the  current  date,  be  signed  by 
each  member  who  participated  in  the  original  examination  if  ]3rac- 
ticable,  copied  in  the  record,  and  forwarded  as  promptly  as  possible. 
If  the  record  book  is  in  the  possession  of  the  bureau,  a  copy  of  the 
amendment  should  be  forwarded  in  order  that  it  may  be  inserted. 

(97)  A  photograph  or  skiagraph  is  always  acceptable  and  fre- 
quently aids  the  bureau  in  the  proper  understanding  of  a  case;  but 
there  is  no  fund  that  can  be  used  for  this  purpose,  and  such  picture, 
if  made,  must  be  at  the  claimant's  expense. 

(98)  Certificates  must  have  the  signatures  of  the  surgeons  on  both 
the  face  and  back.  If  the  names  are  affixed  by  a  stamp  or  written 
by  proxy,  the  certificate  will  be  returned.  If  there  is  a  vacancy  on  the 
board  or  a  member  is  absent,  the  space  for  the  signature  should  be 
filled  by  the  word  "  vacant "  or  "  absent,"  as  the  case  may  require. 

(99)  Certificates  must  never  be  signed  in  blank,  but  the  signatures 
should  be  appended  after  the  certificate  is  otherwise  complete  and 
.after  it  has  been  carefully  read. 

(100)  No  member  of  a  board  should  sign  a  certificate  unless  he  has 
been  present  during  the  examination  and  has  actually  participatecl  in 
the  same  by  assuming  his  share  of  the  work. 

(101)  Every  member  of  the  board  will  be  held  responsible  for 
promptly  constructing  and  forwarding  certificates.  When  the  secre- 
tary is  absent  or  unable  to  prepare  the  certificates,  the  other  mem- 
bers must  assume  the  duties  ordinarily  performed  by  this  officer. 

(102)  The  certificates  should  be  folded  from  the  center  in  four 
■equal  folds,  the  red  order  placed  within,  and  mailed  in  the  penalty 
envelope  provided  for  that  purpose. 

(103)  Certificates  of  examination  for  every  daj^'s  work  should  be 
forwarded  to  the  bureau,  as  a  rule,  within  a  week  or  10  days  from  the 
date  of  the  examination,  never  later  than  one  month  thereafter. 

(104)  Every  certificate  of  examination,  including  those  made  by 
a  full  board  or  member  thereof,  at  the  claimant's  home  or  in  an 
asylum,  or  elsewhere,  must  be  copied  in  the  record. 

(105)  The  record  of  examinations  must  be  a  veritable  transcript 
of  the  certificate,  and  the  signatures  of  the  members  of  the  board 
must  appear  as  in  the  original  certificate,  but  a  transcript  of  the 


14  IlSrSTEUCTIOXS   TO    EXAMINING   SURGEONS. 

claimant's  waiver  in  the  record  book,  in  case  the  full  board  is  not. 
present,  will  not  be  necessary. 

(106)  The  record  book  must  not  be  open  for  the  inspection  of  any- 
one not  properly  authorized  to  see  it.  Except  in  this  record  book, 
the  surgeon  will  not  make  and  retain  for  his  own  use  or  the  use  of 
another  a  copy  of  a  certificate  or  any  part  thereof.  Before  a  record 
book  is  entirely  filled  requisition  for  a  new  one  should  be  made,  and 
the  old  book,  when  completely  filled,  should  be  mailed  to  the  bureau, 
under  the  frank  of  a  penalty  envelope  attached  to  the  package. 

RATING. 

(107)  By  statute  it  is  mandatory  upon  the  boards  an-d  single  sur- 
geons to  "  specifically  state  the  rating  which,  in  their  judgment,  the 
applicant  is  entitled  to."  A  rate  should,  therefore,  be  suggested  for 
each  disability. 

(108)  The  order  for  examination  will  show  the  act  of  Congress 
under  which  the  application  is  made.  The  different  methods  of  rat- 
ing under  the  various  acts  are  described  in  the  succeeding  paragraphs.. 

(109)  Bates  for  certain  disabilities  under  the  general  law  are  es- 
tablished either  by  law  or  rulings  of  the  department,  and  they  will 
be  found  in  the  appended  tables.  Under  this  law  each  disability 
should  be  rated  separatel5^ 

(110)  Eatings  for  enlisted  men  for  other  than  specific  disabilities 
will  be  expressed  in  dollars,  and  $17  is  the  highest  rate  allowed,  ex- 
cept in  grade  cases  hereafter  provided  for. 

Since  anchylosis  of  a  wrist  or  ankle  joint  is  rated  $8,  disabilities; 
compared  therewith  that  are  less  in  degree  are  rated  $2,  $4,  or  $6 ;  dis- 
abilities equivalent  thereto  receive  the  same  rate,  viz,  $8.  A  disability 
greater  in  degree  than  that  caused  by  anchylosis  of  a  wrist  or  ankle^ 
joint,  but  less  than  one  equivalent  to  the  loss  of  a  hand  or  foot,  is  there- 
fore rated  $10,  $12,  $14,  $16,  or  $17. 

Except  in  the  case  of  certain  degrees  of  deafness  mentioned  in  the 
table  of  rates,  the  total  for  the  rank  of  captain  and  certain  fractional 
rates  for  officers  of  higher  rank,  there  are  no  rates  between  $17  and  $21, 
the  latter  being  the  rate  for  a  disability  equivalent  to  the  loss  of  a  hand 
or  foot. 

(111)  Officers  whose  disability  is  less  than  total  will  be  rated  in 
fractions  of  their  total  of  rank,  |-,  |,  |,  as  the  case  may  seem  to  require. 
The  total  of  rank  of  officers  will  be  found  in  the  table  of  rates.  For 
the  same  degree  of  disability  that  would  entitle  an  enlisted  man  to  a 
rate  of  $8  a  month,  which  is  an  enlisted  man's  total,  the  officer  would 
receive  the  total  of  his  rank.  A  lieutenant  colonel  in  the  Army  or  any 
officer  of  higher  rank  would,  therefore,  receive  $30 ;  a  major,  $25 ;  a 
captain,  $20 ;  a  first  lieutenant,  $17 ;  a  second  lieutenant,  $15.  For  a 
degree  of  disabilit}^  that  would  entitle  an  enlisted  man  to  $2  one  of 
these  officers  would  receive  ^  total  of  his  rank ;  $4  for  an  enlisted  man  ' 
would  correspond  to  J-  for  an  officer ;  $6  for  an  enlisted  man  would  cor- 
respond to  f  for  an  officer.     In  this  connection  read  paragi-aph  119. 

(112)  The  rate  will  be  placed  upon  the  certificate  immediate^  fol- 
lowing the  description  of  the  disability,  and  where  there  are  several 
disabilities  the  same  course  shall  be  followed  for  each  of  them. 


IISTSTKUCTIONS   TO   EXAMINHSTG  SURGEONS.  15 

(113)  Besides  these  rates  there  are  grade  rates  provided  for  by  law, 
as  follows : 

(114)  First  grade.  A  permanent  disability  in  a  degree  requiring 
the  regular  aid  and  attendance  of  another  person,  $72  a  month.  When 
the  board  or  surgeon  finds  and  describes  a  disability  of  this  degree,  the 
certificate  must  clcse  with  these  words :  This  claimant  is  "  so  totally 
i'Tid  permanently  helpless  from  (here  name  the  disability)  that  he  re- 
quires the  regular  personal  aid  and  attendance  of  another  person,"  and 
is  entitled  to  $72  a  month. 

(115)  An  intermediate  rate  of  $50  is  provided  by  Congress  in  the 
:act  of  July  14,  1892.  This  rate  is  granted  for  a  disability  in  such  a 
degree  as  to  require  "  the  frequent  and  periodical,  though  not  regular 
and  constant,  personal  aid  and  attendance  of  another  perscn." 

When  this  degree  of  disability  is  found  and  described,  the  certifi- 
cate  must  close  with  the  words:  This  claimant  is  so  disabled  from 

as  to  require  "  the  frequent  and  periodical,  though  not  regular 

and  constant,  personal  aid  and  attendance  of  another  person,"  and  is 
entitled  to  $50  a  month. 

In  recommending  this  rate,  you  will  please  state  whether  the  claim- 
ant requires  aid  in  such  daily  acts  as  dressing,  undressing,  and  attend- 
ing to  the  calls  of  nature. 

(116)  Second  grade.  A  disability  in  a  degree  incapacitating  for 
the  performance  of  any  manual  labor,  $30  a  month.  When  this  degree 
of  disability  is  found  and  described,  ths  C3rtiiicate  must  close  with  the 
words :  This  claimant  is  "  so  disabled  from as  to  be  incapaci- 
tated for  performing  any  manual  labor,"  and  is  entitled  to  $30  a 
month. 

When  it  is  claimed  that  the  soldier  is  unable  to  perform  any  manual 
labor,  it  is  important  to  learn  his  occupation  and  to  state  the  condi- 
tion of  his  muscles  and  of  the  hands,  whether  indicating  the  perform- 
ance of  labor  cr  not. 

(117)  Third  grade.  A  disability  in  a  degree  equivalent  to  the  loss 
of  a  hand  cr  foct  for  the  purposes  of  manual  labor,  $24  a  month. 
When  this  degree  of  disability  is  found  and  described,  the  certificate 

must  close  with  the  words :  This  claimant  is  "  so  disabled  from 

as  to  be  incapacitated  in  a  degree  equivalent  to  the  loss  of  a  hand  or 
foot  for  the  purposes  of  manual  labor,"  and  is  entitled  to  $24  a  month. 

(118)  The  conditions  under  which  grade  rates  are  allowed  are  ex- 
actly the  same  for  both  commissioned  officers  and  privates. 

(119)  Before  a  pensioner  can  receive  an  increase  to  a  grade  rate 
or  to  a  higher  grade  rate,  it  must  be  clearly  shown  that  the  disability 
is  due  to  the  cause  or  causes  for  which  pension  has  been  allowed  and 
the  degree  of  disability  must  be  permanent. 

(120)  Grade  rates  can  not  be  made  by  adding  together  the  rates  for 
minor  disabilities,  and  the  surgeons  will  not  make  such  additions.  It 
is,  however,  proper  to  state  at  the  bottom  of  the  certificate  that,  in 
the  opinion  of  the  board,  the  sum  of  the  disabilities  (not  the  sum  of 
the  rates)  is  equivalent  to  the  loss  of  a  hand  or  foot  as  far  as  manual 
labor  is  concerned,  or  that  the  sum  of  the  disabilities  totally  disquali- 
fies the  claimant  for  manual  labor,  etc.,  as  the  case  may  require. 
Such  a  statement  must  not,  however,  exclude  a  separate  rating  for 
•each  disability. 

(121)  In  rating  an  increase  claim,  you  are  expected  to  rate  the  disa- 
bility and  recognized  sequelae  thereof  precisely  as  though  it  were  an 


16  INSTEUCTIOXS   TO   EXAMINING  SURGEONS. 

original  case,  and  without  regard  to  the  present  rating.  You  will, 
therefore,  rate  such  cases  strictly  upon  the  disabilities  found,  as  your 
judgment  dictates. 

(122)  Rating  under  act  of  June  27^  1890. — The  rate  under  the  act  ot 
June  27,  1890,  as  amended  by  the  act  of  May  9,  1900,  is  based  upon 
inability  to  earn  a  support  by  manual  labor,  due  to  any  mental  or 
phj^sical  disability  or  disabilities  of  a  permanent  character  net  the 
result  of  the  claimant's  own  vicious  habits,  and  will  be  determined 
b}^  giving  due  weight  to  each  and  every  infirmity,  including  these 
due  to  advancing  years,  and  excluding  those  clearly  the  result  of 
vicious  habits. 

The  sum  total  of  such  disabilities  and  infirmities,  as  hindrances  to 
manual  labor,  will  be  estimated  by  the  board  and  rated  collectively  at 
the  end  of  the  certificate  at  $6,  $8, '$10,  or  $12,  as  the  case  mav  wan-ant. 

(123)  The  rate  ultimately  granted  in  all  cases  will  be  determined 
by  this  bureau  in  accordance  with  the  law  and  with  the  degree  of  disa- 
bility shown  to  exist, 

(124)  The  boards  will  receive  orders  marked,  "Act  of  May  11, 
1912."  The  disability  clause  in  this  act  requires  that  in  order  to  re- 
ceive ihQ  only  rate  provided  ($30)  the  applicant  shall  be  unable  to 
perform  manual  labor  by  reason  of  the  causes  for  which  pension  has 
alreach^  been  granted  under  the  general  law. 

The" examinations  under  this  act  will  not  differ  from  those  made 
under  the  general  law;  but  since  the  rate,  if  allowed,  is  practically 
the  second  grade,  they  should  be  made  with  as  great  care  as  those 
demanding  the  second  grade  under  the  general  law. 

VOUCHERS. 

(125)  The  fiscal  year  is  divided  into  four  quarters,  ending  on  Sep- 
tember 30,  December  31,  March  31,  and  June  30,  respectively,  of  each 
year. 

Examinations  made  in  different  quarters  must  not  be  listed  on  the 
same  voucher. 

(126)  Form  3^163  is  for  the  use  of  boards  of  surgeons.  Form  3-164 
for  the  use  of  single  surgeons,  experts,  and  others,  and  Form  3-168  for 
services  and  traveling  expenses  when  an  examination  is  made  at  the 
claimant's  residence. 

Special  instructions  made  necessary  by  the  law  and  by  departmental 
regulations  are  printed  on  each  of  these  blanks. 

(127)  Each  examining  surgeon  who  prepares  a  voucher  for  serv- 
ices (3-163)  should  enter  therein  the  date  of  the  close  of  the  quarter 
after  the  words,  "  Fpr  medical  exammation  of  applicants  for  pension 

during  the  quarter  ending  — ,"  on  both  the  voucher  and  the 

memorandum  voucher, 

(128)  Care  should  be  taken  in  making  the  entries  indicated  by  the 
printed  portions  of  the  voucher,  and  the  totals  must  be  entered  by  the 
surgeon. 

(129)  The  schedule  entries  in  the  voucher  and  memorandum 
voucher  must  agree  in  all  respects.  The  memorandum  is  retained  in 
the  Bureau  of  Pensions,  while  the  voucher,  after  approval,  is  for- 
warded to  the  Chief  Disbursing  Clerk  for  payment.  Vouchers  of 
boards  of  surgeons  are  considered  with  a  view  to  settlement  as  soon 
as  practicable  after  the  ending  of  each  quarter. 


HSrSTEUCTIONS   TO   EXAMINING  SURGEONS.  17 

(130)  The  signature  of  each  surgeon  must  be  personal.  Signatures 
by  stamps  or  by  proxy  will  not  be  accepted.  Each  surgeon  must 
sign  the  certification  corresponding  with  the  column  in  which  his  fees 
are  entered  and  his  post-office  address  in  full,  including  the  number 
and  street,  must  appear  beneath  his  signature,.  The  names  of  cities 
]nust  not  be  abbreviated.  Signatures  and  post-office  addresses  should 
be  jDlainly  written  in  order  that  checks  may  be  correctly  drawn  and 
properly  mailed.  Accuracy  and  legibility  in  the  preparation  of 
accounts  will  facilitate  their  settlement. 

(131)  If  there  is  a  vacancy  on  the  board,  the  word  "vacant" 
should  be  written  in  the  sjDace  provided  for  the  signature  of  the 
missing  member.  When  a  member  of  the  board  is  not  present,  the 
word  "  absent "  should  be  written  in  the  space  provided  for  his  signa- 
ture, unless  there  is  an  ad  interirro  member.  In  the  absence  of  the 
secretary,  another  member  of  the  board  must  not  sign  as  "  acting 
secretary."  The  ad  interim  member  should  sign  in  the  space  provided 
for  the  member  whose  place  he  takes. 

(132)  The  voucher  and  memorandum  voucher  should  be  mailed 
with  the  certificate  or  certificates  to  which  they  refer.^ 

(133)  Vouchers  for  examinations  made  at  an  adjourned  meeting 
should  bear  the  words,  "Adjourned  meeting,"  and  the  date  when  the 
examinations  were  made. 

(134)  No  entries  should  be  made  in  the  spaces  provided  for 
'"''A'pfro'priation:  Fees  of  examinhig  surgeons^  pensions.^  191 — ," 
"  Voucher  No.  — ,"  "  Symbol  — ,"  and  "  Class  symbol  — ." 

(135)  A^^ien  no  examinations  are  made  on  any  regular  meeting  day, 
the  fact  should  be  reported  to  the  bureau  on  penalty  card  (3-347). 

(136)  In  case  of  a  home  examination,  Form  3-168  is  sent  to  the 
surgeon  with  the  order  directing  that  the  claimant  be  examined  at 
his  residence.  The  instructions  on  the  blank  should  be  carefully  read 
before  the  surgeon  incurs  any  expense  in  connection  with  the  exami- 
nation. 

(137)  Each  item  of  expense  must  be  entered  separately.  A  charge 
for  subsistence  must  be  itemized  by  meal  in  every  instance  (each  pay- 
ment for  breakfast,  dinner,  or  supper  for  each  person),  the  amount 
paid  for  lodging,  and  for  each  feed  for  horses. 

(138)  Wlien  the  surgeon  uses  his  own  conveyance  he  is  entitled 
only  to  actual  expenses  that  can  be  definitely  ascertained,  such  as  for 
horse  feed,  gasoline,  and  oil,  and  the  cost  of  each  should  be  itemized. 
No  charge  should  be  made  for  wear  and  tear  on  tires. 

(139)  When  a  railroad,  trolley,  steamboat,  or  other  public  con- 
veyance is  available  it  should  be  used,  and  the  name  of  the  same  and 
the  fare  paid  should  be  entered  in  the  voucher.  Eeceipts  for  such  ex- 
penditures are  not  required. 

(140)  When  a  public  conveyance  is  not  available,  a  definite  state- 
ment to  that  effect  should  appear  in  the  voucher  or  subvoucher,  and 
the  surgeon  must  state  the  special  conditions  which  warranted  the  use 
of  a  private  conveyance  and  whether  an  automobile  or  livery  was 
hired,  with  or  without  a  chauffeur  or  driver. 

When  transportation  other  than  by  rail,  trolley,  or  steamboat  is 
used,  a  receipt  must  be  taken  for  each  item  of  expense  in  excess  of 
$1.  This  receipt  must  be  signed  by  the  person  to  whom  the  money 
is  paid,  and  his  post-office  address  must  be  given  beneath  his  signa- 


18  INSTRUCTIONS  TO   EXAMHSTHsTG  SUEGEONS. 

ture.    Blanks  for  receipts  to  serve  as  subvoiichers  (3-165)  are  for- 
warded with  each  order  for  a  home  examination. 

(141)  In  form  3-168  the  certification  or  oath  must  be  completed 
by  inserting  the  proper  words,  "  is  "  or  "  is  not,"  in  the  spaces  pro- 
vided therefor. 

(142)  When  reimbursement  is  claimed  for  any  item  of  actual  ex- 
pense, surgeons  must  swear  to  their  vouchers.  No  fee  for  adminis- 
tering an  oath  to  a  voucher  will  be  allowed.  The  voucher  may  be 
sworn  to  before  a  postmaster,  assistant  postmaster,  or  other  officials 
designated,  without  charge. 

(143)  When  reimbursement  is  not  claimed  the  voucher  should  not 
be  sworn  to,  but  the  surgeon  should  erase  the  words  "  and  solemnly 
swear,"  and  the  italicized  words,  and  personally  sign  the  certifica- 
tion. When  a  home  examination  is  made  outside  of  the  corporate 
limits  of  both  the  place  of  regular  meeting  of  the  board  and  the  resi- 
dence of  the  surgeon  who  makes  the  examination,  the  fee  is  $5 ;  other- 
wise the  fee  is  $3. 

If  no  expense  is  charged,  the  surgeon  should  indicate  on  the  voucher 
the  places  from  and  to  which  he  traveled  and  the  total  distance 
covered. 

(144)  There  is  no  law  which  warrants  the  payment  of  a  fee  for  an 
amendment  to  a  certificate. 

(145)  An  examination  made  on  an  order  through  a  special  exami- 
ner should  be  listed  on  the  regular  voucher  for  that  day,  and  it  should 
be  noted  on  the  memorandum  side  of  the  voucher  only  that  the  certifi- 
cate was  delivered  to  the  special  examiner. 

With  the  above  exception,  vouchers  should  be  mailed  wit,h  the 
certificates  to  which  they  refer. 


TABLE  OF  RATES. 

Rates  fixed  by  law  for  officers  for  disahilities  ichich  ivould  entitle  a  private  or 

other  enlisted  man  to  $8. 

ARMY. 

Per  month. 

Lieutenant  colonel  and  all  officers  of  higher  rank $30.  00 

Major,  surgeon,  and  paymaster 25.  00 

Captain,  provost  marshal,  and  chaplain 20.  00 

First  lieutenant,  assistant  surgeon,  deputy  provost  marshal,  and  quarter- 
master    17. 00 

Second  lieutenant  and  enrolling  officer 1.5.  00 

All  enlisted  men 8.  00 

NAVY   AND    MARINE   CORPS. 

Captain,  and  all  officers  of  higher  rank,  commander,  lieutenant  com- 
manding, and  master  commanding,  surgeon,  paymaster,  and  chief 
engineer  ranking  with  commander  by  law,  lieutenant  colonel,  and  all 

of  higher  rank  in  Marine  Corps 30.  00 

Lieutenant,  passed  assistant  surgeon,  siargeon,  paymaster,  and  chief  en- 
gineer ranking  with  lieutenant  by  law,  and  major  in  Marine  Corps 25.  00 

Master,  professor  of  mathematics,  assistant  surgeon,  paymaster,  and 

chaplain,  and  captain  in  Marine  Corps 20.00 

First  lieutenant  in  Marine  Corps 17.  00 

First  assistant  engineer,  ensign,  and  pilot,  and  second  lieutenant  in 

Marine  Corps 15.  00 

Cadet  midshipmen,  passed  midshipmen,  midshipmen,  clerks  of  admirals, 
of  paymasters,  and  of  officers  commanding  vessels,  second  and  third 

assistant  engineers,  master's  mate,  and  warrant  officers 10.  00 

All  enlisted  men,  except  warrant  officers 8.  00 

Rates  and  dlsahUities  specified  hy  laiv. 

Loss  of  both  hands 100.  00 

Loss  of  both  feet 100.  00 

Loss  of  both  eyes 100.  00 

Loss  of  an  eye;  the  other  lost  before  enlistment 100.  00 

Regular  aid  and  attendance  (first  grade) 72.00 

Total  disability  in  both  hands 72.  00 

Loss  of  one  hand  and  one  foot 60.  00 

Total  disability  in  one  hand  and  one  foot 60.  00 

Amputation  at  shoulder  or  hip  joint,  or  so  near  joint  as  to  prevent  use  of 

artificial  limb 55.  00 

Frequent  aid  and  attendance ,50.  00 

Total  disability  of  arm  or  leg 46.  00 

Arap'Utation  at  or  above  elbow  or  knee 46.  00 

Loss  of  a  hand  or  a  foot 40.  00 

Total  disability  of  one  hand  or  one  foot 40.  00 

Total  deafness 40.  00 

Inability  to  perform  manual  labor  (second  grade) 30.00 

Disability  equivalent  to  loss  of  hand  or  foot  (third  grade) 24.00 

19 


20  IN-STEUCTIONS   TO   EXAMINING  SURGEONS. 

Table  of  rates  fixed  by  the  Commissioner  of  Pensions  for  certain  disabilities  not 

specified  by  law. 

Per  montli. 

Anchylosis  of  shoulder $12-  00 

Anchylosis  of  elbow 10.  00 

Anchylosis  of  knee 10.  00 

Anchylosis  of  ankle 8-  00 

Anchylosis  of  wrist 8-  00 

Loss  of  sight  of  one  eye 12.  00 

Loss  of  one  eye I'''-  00 

Nearly  total  deafness  of  one  ear 6.  00 

Total  deafness  of  one  ear 10.  00 

Slight  deafness  of  both  ears 6.  00 

Severe  deafness  of  one  ear  and  slight  of  the  other 10.  00 

Nearly  total  deafness  of  one  ear  and  slight  of  the  other 15.  00 

Total  deafness  of  one  ear  and  slight  of  the  other 20.  00 

Severe  deafness  of  both  ears 22.  00 

Total  deafness  of  one  ear  and  severe  of  the  other _ —  2.5.  00 

Deafness  of  both  ears  existing  in  a  degree  nearly  total 27.  00 

Loss  of  palm  of  hand  and  all  the  fingers,  the  thumb  remaining 17.  00 

Loss  of  thumb,  index,  middle,  and  ring  fingers 17.  00 

Loss  of  thumb,  index,  and  middle  fingers 16.  00 

Loss  of  thumb  and  index  finger 12.  00 

Loss  of  thumb  and  little  finger 10.  00 

Loss  of  thumb,  index,  and  little  fingers 16.  00 

Loss  of  thumb 8-  00 

Loss  of  thumb  and  metacarpal  bone 12.  00 

Loss  of  all  the  fingers,  thumb  and  palm  remaining 16.  00 

Loss  of  index,  middle,  and  ring  fingers 16.  00 

Loss  of  middle,  ring,  and  little  fingers 14.  00 

Loss  of  index  and  middle  fingers 8.  00 

Loss  of  little  and  middle  fingers 8.  00 

Loss  of  little  and  ring  fingers 6.  00 

Loss  of  ring  and  middle  fingers 6.  00 

Loss  of  index  and  little  fingers 6.  00 

Loss  of  index  finger 4.  00 

Loss  of  any  other  finger  without  complications 2.  00 

Loss  of  all  the  toes  of  one  foot 10.  00 

Loss  of  great,  second,  and  third  toes 8.  00 

Loss  of  great  toe  and  metatarsal 8.  00 

Loss  of  great  and  second  toes 8.00 

Loss  of  great  toe 6.  00 

Loss  of  any  other  toe  and  metatarsal 6.  00 

Loss  of  any  other  toe 2.  00 

Chopart's  amputation  of  foot,  with  good  results 14.  00 

PirogofC's  modification  of  Syme's 17.  00 

Inguinal  hernia  which  passes  through  the  external  ring 10.  00 

Inguinal  hernia  which  does  not  pass  through  the  external  ring 6.  00 

Double  inguinal  hernia,  each  of  which  passes  through  the  external  ring_  14.  00 
Double  inguinal  hernia,  one  of  which  passes  through  the  external  ring 

and  the  other  does  not 12.  00 

Double  inguinal  hernia,  neither  of  which  passes  through  the  external 

ring 8-  00 

Femoral  hernia 10.  00 

Thos.  Featheestonhatjgh, 

Medical  Referee. 

Approved  :  January  3,  1916.  , 
G.  M.  Saltzgaber,  Commissioner. 


II^DEX. 


Paragraphs. 

Adjourned  meeting,  voucher  for,  how  made 133 

when   to   hold 29 

Age,  effects  of,  when  excluded 45 

effects   of,   when   included 122 

Amputation,  how  to  describe ' 48-52 

Applicants,  number  to  be  examined  in  one  day 28 

privileges  of  26 

statements    of    27 

Asthma    68 

Bladder,    diseases   of 70 

Blanks,    requisition    for 39 

Boards,  absence  or  death  of  a  member 6-8" 

adjourned    meeting    of 29 

appointment  of 1 

change  of  residence  of  member 9 

communications  to,  how  to  be  treated 25 

correspondence  with  dissatisfied  claimant  not  to  be  held 34 

legal  holiday  4 

majority  and  minority  reports  of 23 

employment  of  clerk  for 24 

one  member  not  to  make  an  examination 18 

organization  of 2 

place  of  meeting,  change  of 3 

secretary  being  absent,  duty  to  be  performed  by  another  member  101 

time  of  meeting  of 4,  5 

vouchers    of   - 125-145 

Books,  record- 106 

Brain,    diseases   of 61-64 

Catarrh    ( naso-pharyngeal ) 83 

Certificates,  abbreviations  in,  not  allowed 91 

must  be  copied  in  record  book 104 

amendment   of 96 

construction    of 91 

copies  of,  must  be  verbatim 105 

copies  of,  not  for  personal  use 106 

correction    of 96 

date    of 94 

date  of  adjourned  meeting 29 

disabilities  to  be  entered  in  order 42 

folding   of 102 

heart  and  lungs  to  be  described 46 

legibility  of;  typewriter  may  be  used 91 

marginal  entries  on,  not  allowed 91 

not  to  be  signed   in  blank 99 

prompt  forwarding  of 103 

use  of  additional  blank 92 

use  of  stamp  for  signature  prohibited 98 

undiluted  ink  should  be  used 91 

when  not  accepted  as  valid 18 

Claimant,  citation  of 30 

failure  to  appear  within  specified  time 15 

not  to  be  examined  by  board  of  which  he  is  a  member 37 

signature  by  mark  must  be  witnessed 19 

when  to  be  examined  at  other  than  specified  date 38 

21 


22  INDEX. 

Paragraphs. 

Claims,  increase,  how  to  rate 121 

Clothing,  when  to  be  removed 40 

Deafness 84r-90 

Deformities . 47 

Diarrhea 75 

Disabilities,  arrangement  of,  in  certificate 42 

degree  of,  not  to  be  discussed  with  claimant 34 

all  existing,  to  be  described 41 

the  result  of  age 45, 122 

Ears,  diseases  of 84 

Epilepsy 61 

Examinations,  at  adjourned  meeting 29 

by  civil  surgeon 11 

fees  for 28 

home,  when  made  or  not  to  be  made 31 

home,  fees  for 32 

not  to  be  made  by  one  member  of  a  board 18 

of  a  member  of  a  board  not  to  be  made  by  board 37 

only  members  of  board  and  clerk  to  be  present  when  made 

(except  as  provided) 24 

orders  for 12, 18, 14 

orders  for,  when  to  be  returned 15, 16 

results  of,  not  to  be  revealed 34 

special  examiner  may  be  present 24 

test,  when  ordered  and  how  to  be  made 22 

through  special  examiner 145 

Examining  surgeons,  can  not  make  an  affidavit  unless  claimant's  family 

physician 35 

can  not  accept  fee  for  official  examination 36 

must  participate  in  examination  to  be  entitled  to  fee_      100 

must  not  act  as  attorney  in  pension  claims 10 

must  read  certificate  before  signing 99 

should   make   a   statement   if   they   have   personal 

knowledge  of  a  claimant's  disability 43,  44 

Expenses  for  home  examinations , 136-148 

Eye,  loss  of  sight  of 82 

Eyes,  diseases  of . 77-81 

Fees 28,  32,  86, 143 

Foot,  total  disability  of 53 

Genital  organs,  diseases  of 71 

Grade  rates 113-120 

Gunshot  wounds 47 

Hand,  total  disability  of ' 53 

Hearing,  impairment  of 84r-89 

Heart,  diseases  of 67 

Hemorrhoids  (diseases  of  rectum) 76 

Hernia 54-56 

Holidays,  legal 4 

Hydrocele 72 

Impaired  vision 79-81 

Injuries 47 

Insanity 62 

Kidneys,  diseases  of : 69 

Limbs,  total  disability  of 53 

Liver,  diseases  of 60,  75 

Lungs,  diseases  of 66  ' 

Malarial  poisoning 59,  60 

Nervous  system,  diseases  of 61-64 

Photographs,  when  desirable  and  how  to  be  furnished 97 

Quarters,  ending  of 127 

Rates,  act  June  27,  1890 122 

allowed,  will  be  determined  by  bureau 123 

basis  for 110 

for  disability,  act  May  11,  1912 124 

for  enlisted  men 110 


INDEX.  23 

Rates,  act  June  27,  1890 — Continued.  Paragraphs. 

fixed  by  orders,  rulings,  and  law 109 

grade 113-120 

grade,  not  to  be  made  by  adding  rates  together 120 

in  increase  claims,  how  to  make 121 

must  not  be  discussed  in  claimant's  hearing 34 

ofRcei-s 111 

should  follow  description  of  disability 112 

Records,  how  to  keep 104 

not  to  be  open  to  inspection 106 

their  return,  and  requisition  for  record  book 106 

Rectum,  diseases  of 76 

Rheumatism 58 

Signatures  on  certificates 98 

Skiagraphs   , 97 

Spinal  cord,  diseases  of 61-64 

Sunstroke  and  results 65 

Surgeons,  can  not  delegate  power 6 

change  of  residence  of 9 

civil,  when  and  how  selected 11 

inability  to  perform  duty,  to  notify  bureau 6,  33 

leave  of  absence  of 7,  8 

Syphilis 74 

Tables  of  rates Appended 

Truss,  correspondence  relative  to (note)         56 

Typewriter,  use  of 91 

Urinary  organs,  diseases  of 69,  70 

Urine,   analysis  of 69 

Varicose  veins 57 

Varicocele 73 

Venereal  diseases 71,  74 

Vicious  habits 71,  74,  95, 122 

Vision,  impairment  of 79-81 

Vouchers  and  subvouchers 125-145 

approved  at  ending  of  quarter 129 

addresses  on,  to  be  plainly  written 130 

ending  of  quarter  to  appear  on 127 

expenses  to  be  itemized  on 137 

for  home  examinations 136-143 

forms   for 126 

for  examinations  at  adjourned  meetings 133 

for  expenses  when  surgeon's  conveyance  used 138 

for  amendments,  not  to  be  made 144 

for  examination  through  special  examiner 145 

"  is  "  or  "  is  not,"  when  to  be  used  in  oath  or  certification  to 141 

oath  to,  when  required  and  when  not  required 142, 143 

schedule  entries  on,  how  made 129 

signatures  on,  must  be  personal 130 

spaces  on,  reserved , 134 

statement  on,  when  public  conveyance  is  used 139 

subvouchers,  when  to  be  used 140 

totals,  to  be  entered  on 128 

to  be  mailed  with  certificates 132 

"  vacant  "   and   "  absent,"   how   used   in 131 


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